MEDICARE: DR. NEDA RATANAWONGSA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A76954	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D0061811	OTHER	MD	MARYLAND LICENSE
2	A76954	OTHER	CA	CALIFORNIA STATE LICENSE

General Provider Information

NPI Number	:	1598769002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NEDA RATANAWONGSA MD

Provider Business Mailing Address
First Line	:	1001 POTRERO AVE
Second Line	:	1M GENERAL MEDICINE CLINIC
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94110-3518
Country	:	US
Telephone Number	:	410-206-8494
Fax Number	:	415-206-6115

Provider Business Practice Location Address
First Line	:	1001 POTRERO AVE
Second Line	:	1M GENERAL MEDICINE CLINIC
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94110-3518
Country	:	US
Telephone Number	:	410-206-8494
Fax Number	:	415-206-6115

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	10/01/2014

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